NCL Practice Nurse & HCA session – bowel screening 19/10/16

What we will cover… Bowel screening programme Screening pathway The role of GP practice in supporting patient participation Endorse NHS bowel screening and support We are going to look at how screening impacts your practice population and how your role could make a difference. Overview followed by details of screening programmes, local uptake, ending with what you can do in your practices. We’ll have a few discussions and have time for Q & A at the end but please stop me at any point if you do have any questions.

Bowel cancer screening programme.. What do you think the local uptake is? Local area information about what the screening uptake is for: Bowel [insert] Data available here: http://fingertips.phe.org.uk/profile/cancerservices People who are under the age CANNOT opt in to screening but people who are over the age CAN opt in to Bowel screening. (NB Wales and Northern Ireland and don’t offer bowel cancer screening to the over 74s) National Screening Target The bowel cancer screening uptake target is 60% for England, Wales and Scotland, but the ministerial target for Bowel cancer screening in Northern Ireland is 55% The Taskforce has recommended aiming for/achieving 75% (assuming that FIT would be introduced). Why does the programme exist? GFOBT screening has been shown to reduce bowel cancer mortality by 25% in those who take part. HPE INFO: Use of FOBt in some symptomatic patients, as was recommended by NICE (http://publications.cancerresearchuk.org/downloads/product/NICE-P3-16_text_poster.pdf - see change in bowel pattern , Without rectal bleeding <60) We know that some areas aren't commissioning gFOBt for those certain patients, and that they're opting to put them onto an endoscopy pathway instead. In time, we may also see FIT become more widely used for symptomatic patients but there are still some things to sort out about that (ie regarding thresholds, and what the process should be for patients - do they not have endoscopy if 'negative', or do they get put on a routine rather than an urgent pathway)

NCL Bowel Cancer screening coverage data December 2015 CCG No. of eligible people No. screened in last 30 months Uptake % in six months 2.5year coverage % Barnet 46547 23202 47 49.8 Camden 21784 10650 45.1 48.9 Enfield 35747 18945 50.2 53 Haringey 27744 13583 46.3 49 Islington 19788 9662 44.4 48.8 National standards Bowel screening : Minimum > 52% Achievable 60%

Key Point: It is the person’s choice whether to take part, but you can help them make that decision to participate or not, by making sure everyone is aware of the programme, knows the benefits as well as harms and any barriers to participation are minimised. Talk through the slide. Key point - lack of evidence regarding overdiagnosis and bowel screening (could be a factor but we're not concerned at the moment that it's significantly affecting the balance of benefits and harms), just in case GPs have heard about it in regards to breast screening and we don't want them tarring all programmes with the same brush. Informed consent – CRUK is committed to informed choice with respect to screening participation. Screening has both benefits and harms, and these much be communicated properly. Please remember – a normal result does not guarantee the patient not having or developing bowel cancer in the future. Being aware of the symptoms of bowel cancer is important too.

The Screening Pathway 5 programme hubs in England – contact information appendix 3 of guide. Practices receive notification (hard copy of letter) that the patient did not respond. For electronic notification practices must opt in – contact screening hub for more information.

FOBt Kit • 4 weeks after 2nd reminder letter is sent *England only* Letters are sent to the person before and after FOBT is sent. Bowel screening invitation process. •             Patient receives 1st invitation letter to screen on or close to their 60th birthday •             Approximately 2 weeks later patient receives FOBt kit in the post •             4 weeks after 2nd reminder letter is sent •             The ‘screening episode’ is closed after 13 weeks if not responded to (13 weeks from time received FOBT) •             The patient will be recalled for screening in 2 years time •             A patient that has not been screened within 2 years can telephone anytime to request a kit

Barriers Difficulty in completing the test Unable to catch sample Don’t understand the test Unsure about who to call to arrange bowel screening Procrastinating when the FOB test /appointment letter comes through Worried about finding cancer Low perceived risk of getting bowel cancer There are cultural barriers Feeling disgust about the test Not understanding that they have to do the test more than once Practice staff are unsure about who isn't completing the FOB test People with learning disabilities typically need support from carers to understand and do the test, so uptake is much lower, BOTH need support Why do you think people do not get screened? What do you imagine they think when they get the screening kit in the post? How would you feel and would anything stop you from doing it?

Methods Many people mention finding the test disgusting and we see a lot of ‘poo faces’ being pulled when we talk abut the test. We try to help people come up with ideas on how to catch their poo without getting their hands dirty. Other ideas to help practice staff to help patients? Can you think of anything else? (Prompt: Lid of an old egg box/ washed out takeaway container / plastic grape container <show these objects if you have them with you>) It is ok if people wee on the sample but not if the stool has been in the water, because there could be chemicals etc in the water from cleaning fluids.

What can you do to support your practice population?

Practical tips TRAINING Provide training to all of your staff KNOW THE TEST Being familiar with the FOBt test kit, can help practice staff explain it to patients. DISPLAY SCREENING INFORMATION Information can be displayed in the practice to alert people to bowel screening SIGN UP TO RECEIVE ELECTRONIC RESULTS These are available for bowel cancer screening and can be requested from the Bowel Cancer Screening Hub. Automatically READ coded. USE PRACTICE DATA You could check that the contact details of people aged 60 and over are accurate Consider checking how your practice’s uptake and coverage compares with local and national averages. Show: FOBt kit and fake poo (if applicable) ; accompanying letter / leaflet; leaflet for people with learning difficulties; letters from the screening hub) Consider what information to display – ideas are available under actions section of guide Play CRUK Bowel screening animation (not embedded due to technical issues but it is saved in the resources folder – with and without subtitles) https://youtu.be/m2f-wY0C_1Q (Play NHS one if any problems)

GP ENDORSEMENT Might be useful to reference some evidence based examples from the online hub. GP endorsement template, text brief and phone script in guide. UK study- Talk about study from British Journal Of Cancer (Hewitson et al 2011) about what helps -GP endorsement was effective in increasing uptake. Shown to increase uptake by 6%. Note: London and other areas are introducing GP banner on their invitation letter. Evidence shows that people who have done the test once are more likely to do it again at a future invitation round. Animation videos useful CRUK Animation video (without subtitles) https://www.youtube.com/watch?v=m2f-wY0C_1Q With subtitles How to do the bowel cancer screening test (subtitled version) Poo song Scotland - https://www.youtube.com/watch?v=UrwA_p8H6WY For details of more interventions see Cancer Research UK’s Evidence and Intelligence Hub: http://www.cancerresearchuk.org/health-professional/early-diagnosis-activities/bowel-screening-projects-and-resources/evidence-on-increasing-bowel-screening-uptake

Tested via patient sounding board Jan 2016

What are we doing? What works well? What doesn’t work so well and why? What could we do? What are we going to do (first)? Discuss what you are currently doing in your practices. What works well? What doesn’t work so well and why? Write answers on the post its and stick the post it notes on the corresponding piece of flipchart paper that’s stuck up on the wall. At the end, read out a few from each flipchart paper and allow time for very brief discussion. Encourage attendees to look at them in more detail at the end. Agree some simple actions. Key points: Sharing best practice - please provide any insights back to the ED team.

Key Points: ‘Bowel Screening can detect the invisible early signs of bowel cancer’ We can help people to understand and undertake screening by helping them to break some of the common barriers down. Many people will benefit from being shown how to use the kit. Insert local update data – could you access via Fingertips? Screening and Imms team might be able to provide more current data. Have you a local case story that you can use?

Bowel Screening Order via publications link: http://publications.cancerresearchuk.org/search-results/search-results.html?filter_type=6&filter_action=0&filter_name=SearchTerm&filter_value=card&x=0&y=0 Hard copies of the guide can be sourced via your HPE Facilitator.

Initiatives in London The Bowel Screening Hub started sending GP Endorsement letters from June 2016 following agreement with practices. The GPE ASCEND trial showed that this low-cost approach led to an overall increase in screening uptake Enhanced reminder letters were introduced to the bowel screening programme in April 2016. The ASCEND trial showed that this intervention increased uptake. The increase was greater in more deprived socio-economic groups. For more information contact Transforming Cancer Services Team London - secsu.tcstlondon@nhs.net   Might be useful to reference some evidence based examples from the online hub. GP endorsement template, text brief and phone script in guide. UK study- Talk about study from British Journal Of Cancer (Hewitson et al 2011) about what helps -GP endorsement was effective in increasing uptake. Shown to increase uptake by 6%. Note: London and other areas are introducing GP banner on their invitation letter. Evidence shows that people who have done the test once are more likely to do it again at a future invitation round. Animation videos useful CRUK Animation video (without subtitles) https://www.youtube.com/watch?v=m2f-wY0C_1Q With subtitles How to do the bowel cancer screening test (subtitled version) Poo song Scotland - https://www.youtube.com/watch?v=UrwA_p8H6WY For details of more interventions see Cancer Research UK’s Evidence and Intelligence Hub: http://www.cancerresearchuk.org/health-professional/early-diagnosis-activities/bowel-screening-projects-and-resources/evidence-on-increasing-bowel-screening-uptake

Bowel Scope Date of roll out of bowel scope Why does the programme exist? Bowel scope screening has been shown in the intervention group, CRC incidence was reduced by 23% and mortality by 31% http://www.sciencedirect.com/science/article/pii/S014067361060551X Date of roll out of bowel scope Camden & Islington CCGs – commencing January 2017 Barnet & Haringey CCGs – commenced 2015,completion date TBC Enfield CCG – commencing July 2017

FIT FIT (Faecal Immunochemical Test) gFOBt (guaiac Faecal Occult Blood test) Single faecal sample Six faecal samples from three bowel motions Sample put into a plastic bottle Sample put onto cardboard Higher participation rate than with gFOBt Lower participation rate than with FIT More expensive than gFOBt Less expensive than FIT Automated objective instrument analysis Subjective visual assessment Measures human blood Measures any blood, including that in the diet Higher detection of cancers and adenomas Lower detection of cancers and adenomas Adjustable Hb cut-off concentration Non-adjustable Hb cut-off concentration The national screening committee has recommended that FIT replaces gFOBt. Use of this simpler and more accurate test is likely to begin in Spring 2018

THANK YOU Christine Harding CR-UK Facilitator Christine.harding@cancer.org.uk 07826 537210 [Note – Ensure you tell attendees when they will next hear from you and ask them to fill in the evaluations and everyone has put up their post it]